Rheumatic Heart Disease

&
Valvular Heart Disease

IWAN N BOESTAN MD
Rheumatic Heart Disease
Demam Rheumatik

1. Penyakit jaringan ikat/ sistemik (inflamasi)

2. Sub akut/ kronis
3. Terjadi setelah 1-4 minggu infeksi streptokokus beta
hemolitikus grup A( tonsilitis, nasofaringitis, otitis media)
4. Diperkirakan karena reaksi antigen antibodi
5. Insidens tertinggi umur 5-15 tahun, jarang <4 tahun atau
> 50 tahun.
6. Pada daerah epidemik  3% setelah URI. Pada daerah
endemik  0,3% setelahURI
7. Mengenai keluarga dengan sosio ekonomi rendah
Patologi

1. Dapat mengenai:
Endokardium, Miokardium, Perikardium
Paru, pleura, peritoneum
otak, sendi, kulit dll
2. Lesi spesifik berupa
Perivascular granulomatus reaction
dan vasculitis (Aschoff nodule/body)
3. Katup mitral terkena ± 75-80%
Katup aorta terkena ± 30%
Katup trkuspid 5%
katup pulmonal 5%
4. Dapat sembuh sempurna atau terjadi Progressive scarring
karena inflamasinya menjadi subakut atau kronis selama
beberapa bulan/ tahun.
Diagnosis
Treatment

1. General measures
Hospitalization-Bed Rest

2. Antimicrobial therapy
Eradication ( even if cultures negative )
Followed Long Term Prophylaxis

3. Management of Heart Failure

4. Suppression of the inflammatory process

Aspirin/NSAID

5. Management of chorea
Neuroleptics, benzodiazepines and anti-epileptics
 2. Antimicrobial therapy
Eradication ( even if cultures negative )
Followed Long Term Prophylaxis
 4. Suppression of the inflammatory process
Aspirin/NSAID

It is advisable to avoid premature administration of salicylates or

corticosteroids until the diagnosis of RF is confirmed

Aspirin, 100mg/kg-day divided into 4–5 doses, is the first line of therapy and
is generally adequate for achieving a clinical response.

After achieving the desired initial steady-state concentration for 2 weeks,

the dosage can be decreased to 60–70mg/kg-day for an additional 3–6

Prednisone (1–2mg/kg-day, to a maximum of 80mg/day given once daily, or

in divided doses) is usually the drug of choice. After 2–3 weeks of therapy
the dosage may be decreased by 20–25% each week
Important Definitions
Secondary Prevention/Prophylaxis
Secondary Prevention/Prophylaxis
RHEUMATIC HEART DISEASE

• Merupakan gejala sisa (sequelae) dari demam rematik akut

• Mengenai katub jantung terutama katub aorta & katub mitral
 Mitral Stenosis
Symptoms
Dyspnea ( Most Common, DOE, orthopnea, PND, Pulm Edema )
Palpitation/Irregular pulse ( 30-40% Atrial Arrhythmia
Others : Hemoptysis, embolic events

Signs
Accentuated S1, Accentuted P component of S2
Opening Snap
Diastolic mid-diastolic rumbling murmur heard at the apex
Signs of RHF ( JVP, Hepatomegaly,Ascites,peripheral edema )
 Mitral Stenosis : CXR

Classic features are LA enlargement ( Double Contour ) with normal LV

contour and enlarged pulmonary artery
Others : congestive, kerlery B, MC calcification, hemosiderosis
 Mitral Stenosis : ECG

Sinus Rhythm : P mitrale, a sign of LA enlargement

Atrial Fibrillation
 Mitral Stenosis : Echo
modality of choice dx & severity

2D :thickening and calcification of the leaflets, with restricted mobility

( Wilkin Score )
Doppler : Estimate pressure gradient
 Mitral Stenosis : Management
There is no medical tx available to reverse mechanical
obstruction to mitral inflow

B-Blocker/CCB
Digoxin
Intermittent Diuretics
Anticoagulation
PTMC or Surgical Valve Replacement
Is the definitive treatment
 Mitral Regurgitasi
Symptoms
Exercise intolerance in the form of exertional dyspnea
Followed by Sx of pulmonary congestion and congestive heart failure

Signs
Brisk carotid upstroke with early peak and rapid decline
Precordial palpation displaced diffuse apex late in the course
Left parasternal pulsations
Auscultation :
soft S1 with a holosystolic, soft-pitched, and blowing murmur that is loudest
at the apex and radiates to the axilla
 MR : CXR & ECG

CXR : LAE, pulmonary edema , PHT

ECG : nonspecific, including LAE,LVH,AF

 MR : Echocardiography

What to find :
LA-LV Volumes, LVEF, Severity MR, Anatomic cause of MR
 MR : The Management
Drugs
Tx for Heart Failure ( diuretic,vasodilator,digoxin, digitalis, amiodarone )
Tx for AF ( B-blocker,CCB, anticoagulation )

Valve Repair
Interventional Repair or Surgical

Valve Replacement
Surgical ( At this moment )
 Aortic Stenosis
Symptoms
Asymptomatic
Exertional Dyspnea
Exertional Angina
Exertional Presyncope-Syncope

Signs
Pulsus tardus et tardus
carotid examination increased wave transmission
Auscultation :
Harsh, loud, crescendo-decrescendo systolic murmur at RUC
radiates to the carotids and to the apex
S2 diminished or paradoxial splitting
 AS : CXR & ECG

CXR : Calcification, post stenotic dilatation

ECG : LVH
Rheumatic Aortic Stenosis : ECHO

• Commisural fusion, tip thickening, cusps retraction

• Secondary calcification
• Late & chronically rheumatic ~ degenerative
Essential Echo ; 2007
Evaluation of Px w/ HD ; 2002
Asymptomatic
• Mild or moderate stenosis rarely have symptoms or complications
• No medical therapies that have been proven to delay progression of the
leaflet disease
• Reasonable to recommend ‘Primary’ AVR for asymptomatic px with
severe ASAS if they are in a higher risk group

ESC Guidelines 2006

AHA/ACC Guidelines 2006
Otto CM ; UpToDate 16.1 2008
Symptomatic

• Aortic valve replacement is the definitive therapy for severe AS

• Require early surgery, as no medical therapy for AS is able to delay
the inevitability of surgery
• Surgical replacement of the aortic valve is the only effective
treatment for severe AS ( Really ? )

Braundwald’s HD 8th ; 2008

Gaasch; UpToDate 16.1 2008
Transcatheter Aortic Valve Implantation
( TAVI )
Aortic Regurgitation ( Chronic )
Symptoms
Dyspnea ( DOE,Orthopnea,PND )
Nocturnal angina
Splanchnic ischemia and abdominal pain
Palpitation

Signs ( Chronic AR )
Auscultate with patient leaning forward at end-expiration
High pitched holodiastolic descrendo murmur
Austin Flint murmur: Mid to late diastolic apical rumble
Systolic ejection murmur
 AR( Chronic ) : Peripheral Signs
Widened pulse pressure
Apical impulse is hyperdynamic and displaced laterally and inferiorly
S1 is often normal but it might be muffled if the P-R interval is prolonged
A2 may be decreased (with valvular disease) or increased (with aortic root
disease)
Ejection clicks are rare in adult patients
S3 may be present with a dilated LV
Systolic thrill from augmented stroke volume over the heart base
De Musset sign: Head bobbing with pulse
Corrigan pulse: Water hammer pulse
Bisferiens pulse: Two systolic impulses
Traube sign: Pistol shot systolic and diastolic sounds over the femoral artery
Muller sign: Systolic pulsation of the uvula
Duroziez sign: Femoral artery systolic murmur when it is compressed proximally
and diastolic murmur when it is compressed distally
Quincke sign: Capillary pulsations seen by transmitting light through the patient's
fingertips
Hill sign: Popliteal systolic BP exceeds brachial systolic BP by more than 60 mmHg
 AR : CXR & ECG

CXR : cardiomegaly, pulmonary edema, widened mediastinum,

ascending aorta dilatation

ECG : LVH
 AR : Echocardiography

What to find :
LA-LV Volumes, LVEF, Severity AR, Anatomic cause of AR
 AR : The Management
Drugs
Vasodilaors : ACEI, nifedipine, felodipine or hydralazine
CHF : , digoxin, diuretics, hydralazine, nitrates, salt and fluid restrictions

Medical therapy should not substitute for AV surgery when indicated

Valve Replacement
Surgical
 Catheterization laboratories will begin to look more like operating rooms with appropriate
support facilities

Operating rooms will begin to look like catheterization laboratories with fluoroscopy and
cineangiographic capability
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